A 33 year old woman with severe multiple trauma to head, chest, liver and long bones has been in your unit for a week and has been slowly recovering. She suddenly develops acute hypoxia (PaO2 55 on FiO2 of 0.8 + 10cm PEEP) and hypotension (80/46) due to an acute pulmonary embolism. Outline the key features of management, and your rationale for each.
The key features of management and rationale should include:
• Resuscitation: fluids, consideration of further monitoring/investigation, vasoactive support, and evaluation/adjustment of ventilation/FIO2 to increase PaO2.
• Full anti-coagulation unless strong contraindication still exists (eg. worsening cerebral haemorrhages)
• Consideration of thrombolytics based on haemodynamics [eg. echocardiography] (probably contraindicated unless peri-mortem!).
• Consideration of surgical removal if thrombolysis contraindicated and haemodynamically unstable, but would need to tolerate anticoagulation and cardio-pulmonary bypass.
• Consideration of vena caval filter for prevention of further emboli (depending on source of emboli, if unable to anticoagulate etc)
• General supportive care
This, given the haemodynamic instability, is a case of massive pulmonary embolism.
A question like this would benefit from a systematic answer.
- Attention to ABCs, with correction of immediately life threatening complications
- intubation may be required to apply a controlled FiO2
- Increase FiO2 to correct hypoxia
- Fluid boluses to increase right heart filling
- pulmonary vasodilator and inotrope eg. milrinone, to increase forward flow though the pulmonary circulation
- inhaled pulmonary vasodilators, eg nitric oxide or prostacycline
- thrombolysis likely to be absolutely contraindicated given the history of recent trauma
- anticoagulation may be relatively contraindicated if there are evolving intracranial haemorrhagic events
- Rescue therapy
- Clot lysis / clot retrieval by interventional radiology
- VA ECMO if anticoagulation not contraindicated and other measures fail or are not available
- Preventative therapy
- long term anticoagulation
- vena cava filter